Inspection on 06/09/05 for Manor Park Grove, 25

This inspection was carried out on 6th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Manor Park Grove, 25 23/05/08

Manor Park Grove, 25 29/06/07

Manor Park Grove, 25 29/06/06

Manor Park Grove, 25 23/01/06

Manor Park Grove, 25 13/10/04

Manor Park Grove, 25 28/04/04

Manor Park Grove, 25 12/01/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Manor Park Grove, 25 25 Manor Park Grove Northfield Birmingham B31 5ER Lead Inspector Kerry Coulter Unannounced 6 September 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Manor Park Grove, 25 Address 25 Manor Park Grove Northfield Birmingham B1 3Jn 0121 476 2703 0121 476 7529 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) FCH Housing and Care Vacant CRH 4 Category(ies) of Younger people with learning disabilities (4) registration, with number of places Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 13 October 2004 Brief Description of the Service: 25 Manor Park Grove is a purpose built bungalow, which provides accommodation for four men with learning disabilities. It is owned by FCH Housing and Care. The home is situated within a residential housing estate on the site of an old hospital. The home is situated within a cul-de-sac with off road parking. There are local bus services available. Each service user has a single room with a wash hand basin, which have been decorated to individual taste by the staff with assistance from service users. The bathroom has an assisted bath, which has the advantage of automation if required, to assist people with limited mobility. In addition to the bathroom the home has a shower room. To the rear of the home there is a pleasant well-maintained garden. Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Individual care plans need some development to ensure they are regularly reviewed, contain guidance on health needs and set goals, so that these can be measured in the future. The home needs to consider how health action plans for service users can be introduced. This is something that the Government paper, ‘Valuing People’ recommended that each person with a learning disability had by 2005. This is to ensure individuals receive all the care they need to stay healthy. The systems for the administration of medication require improvement to ensure ‘as required’ medication is administered in accordance with the guidelines and strategies in place. Action must be taken to further protect service users from the risk of verbal abuse from one service user who lives at the home. Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 6 Systems to ensure the safety of the service users need to improve to include more regular fire training for staff. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3 The Statement of Purpose does not provide clear information for prospective service users to be clear about the services the home provides to meet their needs. EVIDENCE: The statement of purpose for the home is still in draft form and the document contains several gaps where the detail still needs to be added. It has been required at several inspections that this document is finalised. The service user guide for the home was not available as it could not be located by staff. At the last inspection a draft service user guide was observed that required further improvements, it is therefore unclear if this has been completed. It was previously required that the admission policy and procedure required amendment to include a three-month trial period followed by a review with the service user. A policy was available at this inspection, however it was dated 1995. This document will require review to ensure it reflects the National Minimum Standards with regards to the admission and assessment process. The policy stated that each service is to have its own admission criteria, however this was not available for the home. One service user is aged over 65, this is not within the category of registration of the home. Previous requirements have been made for the Provider to apply for a variation to the registration to accommodate those service users over the age of 65 years. An application has yet to be received by the CSCI. Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 9 It was unclear if the home is still able to meet the needs of one individual service user. Records and discussion with staff indicate that there have been frequent incidents of challenging behaviour. Following a complaint to the CSCI in March 2005 the previous manager of the home agreed to make a referral for a social worker review of the placement of this service user. A referral was made but as yet no review has taken place. The new manager of the home will need to pursue this with Social Care and Health. Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 9 The care planning system in place does not adequately provide staff with all the information they need to satisfactorily meet service users needs. People are supported to take responsible risks, but some work needs to be done on the frequency of reviews. EVIDENCE: Two service user care files were sampled. In general the tenant profiles were found to be detailed and some good work had been undertaken to cross reference these to risk assessments. However some plans had not been reviewed on a six monthly basis and also required further information to be added. One service user is prescribed medication for epilepsy but there was no information within the profile on the type of epilepsy and the support required from staff. Care plans should seek to set targets with outcomes that can be measured. These can subsequently be evaluated at review, and amended or continued as appropriate. Reviews need to indicate who takes part and how decisions are made. There was evidence of involvement from health professionals, for example one service user has a behaviour management strategy that has been devised in liaison with a Community Nurse. It is of concern that staff at the home do not Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 11 appear to be following the care plan in regard to the administration of ‘as required’ medication for this individual. This is further detailed in Standard 20. Some work is required on risk assessments to ensure that they are up to date and reflect individuals’ current support needs. There is evidence that service users are supported to take manageable risks, and staff encourage individuals to have an independent lifestyle as far as possible. Risk assessments were noted to be in place for the home and service users, however many risk assessments sampled for service users had not been reviewed at least six monthly. Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 17 A range of activities is offered in order to promote personal development, participation in the life of the local community and enjoyable leisure time. Service users enjoy a healthy and nutritious diet and exercise choice about what they eat. EVIDENCE: Daily dairies and discussion with staff indicate that service users participate in a variety of daytime occupations. These include structured day centres, and participation in a wide variety of appropriate community based activities. Staff clearly enable service users to take part in a wide variety of community-based activities including education classes, meals out, trips and gardening. The use of taxis, specialist and public transport is available to service users. There was evidence of 1:1 support for activities as well as going out in small groups. On the day of the inspection two service users went out with staff to the Botanical Gardens and a meal out. The hallway had a gallery of photographs of service users and staff enjoying leisure activities outside of the home. The home benefits from a small activity room that has equipment such as games, art materials, stereo and darts. Staff informed the inspector that Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 13 service users regularly use this room and benefit from input from an activity organiser who comes into the home twice a week. The food cupboards, fridge and freezer were well stocked and menus were seen to be satisfactory. A new recording system for meals provided has recently been introduced by the new Assistant Team Leader. They were observed to be an improvement on the previous records both in detail and the frequency that staff were completing them. Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 Arrangements for healthcare are variable with particular attention needed to record healthcare needs within the care plan. The systems for the administration of medication require improvement to ensure ‘as required’ medication is administered in accordance with the guidelines and strategies in place. EVIDENCE: A sample inspection of service users’ health records indicates that service users are receiving routine access to general health services, such as well person’s checks, dentist, eye tests, flu vaccinations and chiropodist. As stated earlier in this report the health needs of one service user require further assessment regarding epilepsy. The home needs to consider how health action plans for service users can be introduced. This is something that the Government paper, ‘Valuing People’ recommended that each person with a learning disability had by 2005. This is to ensure individuals receive all the care they need to stay healthy. It may be that this is an opportune time to engage with the local Community Nurse (Learning Disability) Service in order to move this forward. The CSCI Pharmacy Inspector visited the home in October 2004 and made several requirements to improve medication administration practice. Medication practice in the home has improved since that visit, however the use Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 15 of ‘as required’ medication for one service user requires review. This individual has medication to be used as part of the reactive strategy for managing behaviour. In one four week period this was administered fourteen times and in another twenty four times. The recording from staff was not in sufficient detail to establish if the behaviour strategy plan had been followed before the medication was administered. Additionally, records also did not always record if the medication had proved effective. Some form of auditing should take place to establish the effectiveness of the medication, if it is not effective its use should then be reviewed. Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 The organisation’s policies and procedures with regard to adult protection are adequate. All staff have a responsibility to ensure that they are implemented effectively and correctly. There are some concerns that service users are not being fully protected from the abusive behaviour of another service user. EVIDENCE: The home was observed to have a new adult protection policy, this was satisfactory. Sampled training and development plans for staff did not show that all staff have received adult protection training. CSCI received an anonymous complaint regarding 25 Manor Park Grove in March 2005. The complainant alleged that a service user had verbally and physically abused the other service users who live at the home. The complaint was upheld. Part of findings were that staff had failed to report a number of incidents to the CSCI that had occurred in the home in the period January 2005 up to the day of the investigation. At this inspection it was apparent that incidents had occurred that should have been reported to the CSCI but were not. Discussion with the Assistant Team Leader indicates that this non reporting occurred during the time that the home was without a permanent manager. A new manager is now in place and previous discussions with him at another of FCH’s care homes indicate he is aware of the need to report such incidents. Records indicate that both service users and staff have been subject to verbal abuse. One member of staff was concerned about the effect of this on service users and stated that they are frightened of this individual. An immediate requirement was made for notification of incidents to be made to the CSCI and Social Care and Health. Previous requests to the Social Worker for a review of the placement must be followed up. During the inspection the service user was Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 17 verbally abusive for prolonged periods of time to the member of staff on duty. It was positive however, that the member of staff on duty was heard to deal with the abuse in a calm manner and tried to redirect the service user into more acceptable behaviour. Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 27, 28, 30 Some repairs are required to ensure the home presents as a homely and comfortable environment for the people who live there. Standards of hygiene need to improve to ensure there are effective infection control measures in place and ensure the well being of service users and staff. EVIDENCE: The home provides accommodation on a domestic scale in a modern environment. One service user bedroom was sampled. It was observed to be personalised with plenty of evidence of personal effects and possessions. People were observed to do their own thing, watching television or listening to music, and so on, whenever they wish. Communal areas were observed to be generally well equipped with modern furnishings of a satisfactory quality. The home has a bathroom, separate shower room and separate toilet. The bathroom has a high low bath and chair hoist, and maintenance records were seen for this. The home has a combined lounge/dining area and a separate small activities room. Some repairs are required to areas of plasterwork around some door frames where cracks have occurred due to doors being slammed by a service user. Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 19 The home has a separate laundry, which is sited off the main hallway. As required at the last inspection the washing machine has been replaced with a sluice cycle machine in order to effectively manage soiled linen. The home has an infection control policy in place. Liquid soap and hand towels are provided in the laundry, kitchen and bathrooms/shower rooms and WC to prevent the risk of cross infection. However, some improvement is needed to prevent cross infection as the communal shower chair was observed to be split on the padded seat, exposing the internal foam. This makes it impossible to keep this chair clean from bacteria and germs. The chair must be repaired or replaced. Fridge temperature records show that the temperature is too high for the safe storage of food, this could lead to bacteria developing in the food. Action must be taken to ensure food is stored at a safe temperature. Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 Current staffing levels meet the needs of the service users. EVIDENCE: It was noted that both staff and service users appear comfortable in each other’s company and enjoy a good general rapport. They give support with warmth, friendliness and patience and treat people respectfully. Staffing across the daytime period is two or three staff on shift. Some of the staff are designated ‘day ops’ staff who specifically support service users to access a range of opportunities within the homes and out in the community. Staffing levels appear appropriate to the needs of service users. Staff meeting minutes were examined and demonstrated that a range of issues, including individual welfare updates for service users. Meetings have historically been held on a regular basis but no meetings have occurred since April, a gap of five months. Arrangements need to be made for meetings to recommence. The Inspector had the opportunity to speak with two staff who are new to the home. Both confirmed that they had received an induction. Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 42 The arrangements in place for the promotion of the health, safety and welfare of the service users were variable. EVIDENCE: The home has been without a registered manager for some months. A new manager has now commenced work in the home. Previous discussions indicate that he is experienced in working with individuals who have a learning disability and has previous relevant management experience. An application for registration must be made to CSCI. A number of health and safety documents were sampled. New documentation has recently been introduced by the Manager, these were observed to be concise with information quick to access. An examination of the home’s fire safety records indicate that routine testing of alarms and lights is being carried out at the appropriate frequencies. The records also show that fire drills are being routinely carried out. One service user sometimes does not react to the fire alarms sounding, this will need to be appropriately risk assessed. Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 22 One fire door closure required repair, the Assistant Team Leader was aware of this and had reported it to the maintenance department a couple of days previously. It was therefore confusing that on the day of the inspection a maintenance operative visited the home to repair a chest of drawers and left without repairing the fire door. The member of staff on duty was not heard to ask the maintenance operative about repairs to the door. Records did not show that staff have received fire training on a six monthly basis. Staff were unable to locate an up to date certificate to evidence that electrical portable appliances had been recently tested, the most recent dated certificate was December 2003. Some difficulties have been experienced in ensuring that water is delivered at a temperature that is safe for the service users. Engineers were working in the home at the time of the inspection to resolve this problem. Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 2 x x Standard No 22 23 ENVIRONMENT Score x 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 3 3 x 2 Standard No 11 12 13 14 15 16 17 x 3 3 x x x 3 Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Manor Park Grove, 25 Score x 2 2 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 2 x E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 17 (2), 4(1) (a), Schedule 4 (1), Schedule 1 5 & 17(2) Schedule 4(2) Requirement The home statement of purpose requires amendment to include: - The organisational structure of the home. - The number and size of rooms in the home. Outstanding requirement from 4/8/04 The home requires a service users guide to include: - Summary of statement of purpose. - Terms and conditions in respect of accommodation to be provided, including amount and method of payment, and any additional costs such as mileage. - Standard form of contract. - Most recent inspection report. - Summary of Complaints. - Details of CSCI. Guide to be given to CSCI and each service user. Outstanding requirement from inspection in June 2003. The admission policy and procedure requires review to ensure it reflects the National Minimum Standards. An admission criteria must be available for the home. Timescale for action 30/11/05 2. 1 30/12/05 3. 2 14 30/12/05 Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 25 4. 3 CSA 2000 28 5. 6 15 6. 6 and 19 12(1) & 15 7. 6 and 20 12(1), 13(2) & 15 8. 9 13(4) 9. 10. 11. 19 23 23 12(1) 12(1) 13(6) 12(1) 13(6) The home must apply for a variation to the registration to accommodate those service users over the age of 65 years. Outstanding requirement from 4/6/04. Care plans require further improvement to ensure: - They are reviewed at least six monthly. - Specific support needs are included, for example epilepsy. - Consideration needs to be given to increased service user involvement in the care planning process to include some goal setting within the plan. Clarify if service user has epilepsy and then detail in the care plan the type of epilepsy, likelyhood of occurance and guidance for staff on how to respond if a seizure occurs. Ensure the administration of as required medication is in line with the reactive strategy and protocol. Some form of auditing should take place to establish the effectiveness of the medication, if it is not effective its use should then be reviewed. Ensure service user risk assessments are reviewed six monthly or following any critical incident occuring. The home needs to consider how health action plans for service users can be introduced. Ensure that all staff have received training in adult protection. Notify Social Care and Health of incidents in the home that have impacted on service users from the behaviour of individual service user. Follow up on previous requests for a review of placement. 30/10/05 30/10/05 20/9/05 Immediate requiremen t 11/9/05 Immediate requiremen t 6/10/05 30/11/05 30/11/05 9/9/05 Immediate requiremen t Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 26 12. 13. 23 24 37 23(2)(d) 14. 29 16(2)(g,j) Ensure incidents are reported to CSCI that effect the well being of service users. Audit the environment and complete a schedule of works for the required repairs of damaged plasterwork. Ensure the fridge is maintained at a safe temperature, replace the fridge if necessary. The damaged shower chair must be repaired or replaced to prevent the risk of cross infection. Reintroduce staff meetings. An application must be made to the CSCI to register the manager. Ensure portable electrical appliances are checked by a qualified person to ensure they are safe. Ensure fire door closure to service user bedroom is repaired. The provider must ensure that all staff have received fire training on a six monthly basis. Review the fire risk assessment to include assessing the risk of identified service user not responding to the fire alarms. 30/9/05 15/10/05 15. 29 23(2)(c ) 15/9/05 Immediate requiremen t 15/10/05 16. 17. 18. 33 37 42 18(2) 10 13(4) 30/10/05 30/10/05 30/9/05 Immediate requiremen t 15/9/05 Immediate requiremen t 6/10/05 Immediate requiremen t 20/9/05 Immediate requiremen t 19. 42 13(4) 20. 42 13(4) & 23 13(4) & 23 21. 42 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Manor Park Grove, 25 E54 S16796 Manor Park Grove 25 V248556 Stage 4.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!